Healthcare Provider Details

I. General information

NPI: 1669409223
Provider Name (Legal Business Name): BRIAN PAUL SCOTTOLINE MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 SW GAINES ST CDRC-P
PORTLAND OR
97239-1507
US

IV. Provider business mailing address

707 SW GAINES ST. CDRC-P
PORTLAND OR
97239
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-2613
  • Fax:
Mailing address:
  • Phone: 503-494-2613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA66414
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number160149
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberA66414
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberA66414
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD60211161
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: